Introduction

Very late stent thrombosis (VLST; > 1 year) is a rare but fatal complication due to acute vessel closure. Several factors, including procedure, lesion and patient discontinuation of antiplatelet therapy, are most closely related to its occurrence [1]. Furthermore, neoatherosclerotic plaque rupture is now acknowledged as a potential contributing factor [2]. Although similar rates of early and late stent thrombosis were observed between drug-eluting stent (DES) and bare metal stent (BMS) [3]. Very late stent thrombosis occurs with higher frequency in DES [4]. However, it is even rarer to have a simultaneous two-vessel very late stent thrombosis with a sirolimus-eluting stent (SES), and studies on the pathogeny are lacking.
We report the case of a patient presenting with ST-segment-elevation myocardial infarction (STEMI) and cardiogenic shock who experienced simultaneous VLST in two vessels which occurred 40 months after sirolimus-eluting stent implantation.

Case report

A 56-year-old man presented to the emergency department with severe chest pain within 4 h after onset of symptoms. The ECG showed an ST-segment elevation in I, aVL and V6–V9 (Figure 1). The patient had undergone percutaneous coronary intervention (PCI) in our catheter lab using sirolimus-eluting stents (Firebird, MicroPort) in the left anterior descending (LAD) (3.0 × 33 mm; 16 atm) and in the left circumflex artery (LCX) (2.75 × 33 mm; 10 atm) 40 months prior to admission. Also, 35 months prior to admission, an intervention in a de novo lesion of the right coronary artery (RCA) using an SES (Firebird, MicroPort; 4.0 × 23 mm; 9 atm) followed by balloon angioplasty was performed. At this point in time, no evidence of restenosis was found in the former lesion of the LAD or LCX. Anti-platelet therapy consisting of 100 mg aspirin and 75 mg clopidogrel was prescribed for an intended period of 12 months following percutaneous intervention.
Cardiac catheterization revealed a thrombotic occlusion at the site of the stent implanted in the LAD as well as at the site of the stent in the LCX (Figure 2 A). A temporary pacemaker was inserted, then crossing the lesions of LCX with a guidewire, thrombus aspiration was performed using a thrombus aspiration device (Thrombuster II, KANEKA) starting in the LCX. Intracoronary abciximab followed by intravenous infusion was administered. The angiographic result showed Thrombolysis In Myocardial Infarction (TIMI) 3 flow...


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